Social Action Theory for a Public Health Psychology

Craig K. Ewart Department of Health Policy and Management, Johns Hopkins University

Many illnesses can be prevented or limited by altering advanced disease control and enhanced quality of life in personal behavior, and public health planners have turned ways that would not have been possible in a clinical model. to psychology for guidance in fostering self-protective ac- Early attempts to determine who became sick, and where tivity. A social theory of personal action provides an in- and when, for example, led to significant reductions in tegrative framework for applying psychology to public the prevalence of infectious diseases long before the bio- health, disclosing gaps in our current understanding of logical mechanisms of these illnesses could be explained self-regulation, and generating guidelines for improving or modified. A population perspective can reveal a pre- health promotion at the population level. A social action viously unrecognized environmental hazard or a wide- view emphasizes social interdependence and interaction spread health-endangering personal behavior that when in personal control of health-endangering behavior and altered even slightly may reduce the burden of human proposes mechanisms by which environmental structures suffering and lower the cost of medical care. This per- influence cognitive action schemas, self-goals, and prob- spective has led to public health's long-standing emphasis lem-solving activities critical to sustained behavioral on disease prevention and on viewing the entire com- change. Social action theory clarifies relationships between munity-rather than the individual--as the patient. social and personal empowerment and helps explain stages Public health's interest in individuals and in pro- of self-change. cesses of personal change has increased, however, with mounting evidence linking major health threats to mod- ifiable human behaviors (Sexton, 1979; Surgeon General, Every year millions of people suffer and die of illnesses 1979). Public health is an empirically driven, problem- that could be curbed or eliminated by altering patterns focused enterprise that looks to various disciplines for of personal behavior. Modifiable habits and customs con- needed theoretical and technical resources. Yet those who tribute to malnutrition, communicable diseases, and would apply behavior change methods of psychology to chronic illnesses, and thereby augment a staggering toll populations quickly discover that these efforts can go awry of needless deaths (Elder, 1987). To lower this toll, public (Jeffery, 1989). Interventions directed at individuals can health planners have turned to psychology--and es- prove more expensive than the "passive" environmental pecially to its models of self-regulation--for guidance in prevention strategies long championed in the public health fostering self-protective action among those at risk. Yet movement and may unintentionally "blame the victim" psychological theories and models often seem of limited by implying that people are personally responsible for value when applied to public health problems, and some illnesses caused by unhealthy physical and social envi- public health theorists have questioned their usefulness ronments (Runyan, DeVellis, DeVellis, & Hochbaum, in the global struggle against disease (Jeffery, 1989; Lev- 1982; Williams, 1982). Moreover, the dominant diag- enthal, Cleary, Safer, & Gutman, 1980). I argue that psy- nostic model in public health envisions an interaction chology does have a role to play, but that this role is con- between a host (e.g., disease victim), an agent (e.g., health- strained by inattention to pathways by which social en- damaging organism or substance), and the environment. vironmental phenomena affect cognitive and biologic Psychological theories focus on the host. They explain regulatory processes. I propose a theory of personal action important phenomena of individual learning, memory, designed to foster social-contextual analysis of personal choice, and performance. Yet public health planners often change. This analysis poses important questions for self- have difficultyapplying these theories to the practical tasks regulation theory and discloses new opportunities for of designing protective legislation, educating the public, psychology to contribute to human health and well-being. and fashioning healthier occupational work or living en- vironments (Faden, 1987). These tasks require a multi- Public Health and Psychology leveled conception that views host processes as subeom- The term public health embraces a diverse array of prob- ponents of larger social and environmental systems. lem-solving and health-protective activities inspired by the practice of viewing illnesses in a social context. By Preparation of this manuscript was supported in part by Grant R01- relating the afflictions of individuals to the groups to HL36298 from the National Heart, Lung,and Blood Institute. which they belong or to the environments in which they I thank LawrenceKincaid and DonaldSteinwachs for their helpful comments on an earlier draft. work and live, the public health outlook differs from that Correspondenceconcerning this article shouldbe addressedto Craig of clinical medicine, which treats diseases as attributes K. Ewart, Health Services R & D Center, Johns Hopkins School of of isolated sufferers. This social-contextual approach has Hygieneand PublicHealth, 624 North Broadway,Baltimore, MD 21205.

September 1991 • American Psychologist 931 Copyright 1991 by the American Psychological Association, Inc. 0003-066X/91/$2.00 Vol. 46, No. 9, 931-946 Self-Regulation system, so behavioral interventions strengthen self-reg- ulatory systems that foster capacity for self-protective ac- By the mid 1970s, interventions based on social learning tion (Ewart, in press). These self-regulatory systems can principles were seen to offer the most effective, widely be viewed as interconnected cybernetic control loops op- applicable method for changing behaviors that contrib- erating at physiologic, cognitive, and social levels (See- uted to leading causes of preventable deaths (e.g., Ban- man, 1989).1 dura, 1969; Kanfer, 1977). With its emphasis on cognitive Applying the framework to an analysis of population mediation of learning through modeling and vicarious interventions discloses gaps in our current understanding reinforcement, social learning theory stimulated the cre- of self-regnlation and suggests how public health strategies ation of interventions to prevent heart disease and cancer targeting individuals might be improved. To highlight by altering habits related to eating (Stunkard & Penick, these problems and possibilities, I apply here the tripartite 1979), smoking (Leventhal & Cleary, 1980), exercise model to self-regulation of coronary and cancer risk be- (Martin et al., 1984), and substance use (Marlatt & Gor- haviors involving diet, physical activity, and tobacco or don, 1985). These developments provided both a theo- alcohol use, as these have generated the largest health retical and a practical foundation for communitywide in- literature on self-regnlation. The model's three dimen- terventions such as the Stanford Five-Community Study sions (Figure 1), respectively, emphasize the role of social (Farquhar et al., 1985) and the Minnesota Heart Health context in maintaining health routines or habits (action Program (Blackburn et al., 1984). During the 1980s, so- state dimension), provide a causal framework linking self- cial learning theorists expanded their purview to include change processes to interpersonal environments (process a variety of cognitive phenomena subsumed under the dimension), and specify macrosocial and environmental rubric "social-cognitive theory" (Bandura, 1986), and influences that empower or constrain personal change control and systems concepts were incorporated into (contextual dimension). 2 models of self-regulation (Bandura, 1989; Carver & Scheier, 1981; Hyland, 1988; Schwartz, 1983). Goals, Self-Regulation as an Action State feedback functions, and attendant systems constructs helped delineate processes by which people overcame de- The first challenge in public health intervention is to de- structive behavior patterns and strengthened self-protec- fine appropriate self-regulatory goals. In most cases, pre- tive capabilities (Weinstein, 1988). vention entails creating self-protective habits in the form of highly routinized and "automatic" action sequences Social Action Theory that lower personal risk. Health habits are easily repre- Although these developments expand a theory of personal sented by a simple action-outcome feedback loop, in change, they do not meet public health's need for a con- which self-regulation is a condition of self-sustaining, dy- textual theory of individual action that incorporates namic equillibrium between self-protective activities and modifiable social and personal mechanisms of self-control their experienced biologic, emotional, and social conse- within an environmental model. Those who would en- quences. Habitual eating, exercise, smoking, or drinking courage self-regulation on a wide scale require a frame- activities tend to follow predictable scripts, in which suc- work for solving the problems that have hindered attempts cessive events in an action sequence reinforce preceding to implement self-change as a public health strategy acts and guide subsequent action components (Kazdin, (Leventhal, Zimmerman, & Gutman, 1984), including 1984; Schank & Abelson, 1977). These scripts tend to be the challenge of defining appropriate self-regulatory goals, highly integrated, in that one can perform them without the problem of identifying causal mechanisms that can consciously attending to component actions that compose be activated to facilitate these goals, and the task of un- the larger sequence (Abelson, 1981). Moreover, they often covering social-contextual influences that constrain or co-occur with other habitual acts, as when eating, smok- enhance self-regulatory mechanisms and thus provide ing, or drinking are embedded in social or recreational targets for political, economic, or organizational change. events. This makes unwanted habits hard to change; con- This article responds to this need by proposing a versely, the assimilation of desired habits into other rou- conceptual model with three dimensions representing self- regulation as a desired action state, an ensemble of in- ' "Behavioralinnoculation" can be effectedvia legal or environ- terrelated change mechanisms, and a subcomponent of mentalchanges that encouragepeople to take self-protectiveaction against larger social environmental systems that contextually de- a healththreat. Lawsrequiring seat-belt use and buzzersreminding pas- termine how personal change mechanisms operate. The sengers to attach their belts represent innoculationapproaches to pre- proposed framework seeks to identify self-regulatory venting automobile injuries, whereas laws mandatingair bags in vehi- cles--by reducingthe need for personalaction--represent public health's phenomena of public health importance, stimulate a de- "sanitary" tradition of removing health threats from human environ- sire to understand them, and set forth basic assumptions ments. Research on self-regulationthus may aid legaland environmental to guide the development of new theories, models, and intervention, as well as public education. exemplars (Kuhn, 1977; Rappaport, 1987). In this view, 2 The model also applies to behaviorscontributing to malnutrition and to communicablediseases that, althoughless studied by psychologists, interventions to encourage self-regulation belong to the account for a far greater portion of the world's preventable deaths. For public health tradition of innoculation. As immunization applicationsto third-worldhealth problems and settings,see Elder(1987), strengthens the self-regulatory capabilities of the immune and Elder, Schmid, Hovell,Molgaard, and Graeff, (1989).

932 September 1991 • American Psychologist ical psychology (Woodward, 1982). Yet attempts to mod- Figure 1 ify health habits in community-based prevention disclose Social-Contextual Model of Self-Regulation that the intrapersonal control loops emphasized in psy- 1. SELF-REGULATORY GOALS: chological theories are connected to interpersonal control systems: Personal action scripts are socially intertwined with scripts of family members, friends, or others in ways Health Habits that pose significant obstacles to long-term change - Action-Outcome Control Loops (M. H. Becker & Green, 1975; Sallis, Grossman, Pinski, Patterson, & Nader, 1987). Public health applications re- veal a need to expand individually focused action state 2. SELF-REGULATORY PROCESSES: conceptions by including interdependence with others as a determinant of sustained behavior change. Change Mechanisms Health Habits Social Interdependence

- Goals - Expectations - Action-Outcome Figure 2 incorporates social interdependence into the ac- - Strategies Control Loops - Capabilities tion state model. A close social relationship is one in which important action scripts of the people involved are interlinked; each individual in the relationship has the 3. SOCIAL ACTION MODEL: ability to facilitate or impede the other's sequences and Action Contexts- Change Mechanisms ~ [ Health Habits thus affect their ability to attain valued goals related to love, work, self-care, or other desired ends (Clark & Reis, - Physical - Goals - Action-Outcome - Social - Expectations Control Loops 1988). These interlinked scripts frequently serve multiple - Biological Strategies - Mood/Arousal Capabilities goals. Preparing and sharing a meal, for example, allows family members to satisfy hunger, give and receive emo- Note. 1. The goal of self-regulation is to create action-outcome control loops tional support, amuse themselves, and plan the next day's that sustain health-protective routines; 2. the process of self-regulation entails activities (Bersheid, 1983). Social closeness can be defined activating social-cognitive mechanisms to generate desired control loops; 3. social and biological contexts of self-regulation facilitate or constrain these in terms of the number of interlinked scripts and by the mechanisms and thus determine long-term success in habit modification. number of goals these linked sequences serve. As closeness increases, so does the probability that one person's at- tempt to alter a simple routine will disrupt valued routines tines renders protective diet, exercise, or similar regimens and goals of intimate others, causing frustration and anger easier to sustain (Ewart, in press). (Manne & Zautra, 1989; Ruehlman & Wolchik, 1988). In this feedback model, actions are guided by their Changes that disrupt action sequences at a point close to consequences in a negative control loop; variations in monitored outcomes (immediate and delayed) evoke compensating behavioral adjustments. The result is a steady but continuously oscillating action state, in which Figure 2 Action State Model Representing Self-Regulation as a the frequency of the diet, exercise, or other behavior fluc- Negative Control Loop Maintaining Habitual Action tuates around some stable set point (D. H. Ford, 1987). Sequences or Routines The control loop implies that the starting place in devel- oping public health interventions is with an analysis of the relationships between health-endangering action se- SOCIAL INTERDEPENDENCE quences and their experienced effects. This analysis can - Action Linkage disclose the point at which problematic action scripts are - Goal Congruence most vulnerable to prevention, and suggest effective pro- cedures for constructing new scripts to protect health (Ewart, in press). The action state model thus helps the intervention planner identify critical action components and specify desired replacement sequences and outcomes. The functional feedback loop described here rep- resents a dominant view in current models of self-regu- HEALTH OUTCOMES PROTECTIVE lation and, in a broader sense, exemplifies an evolutionary ACTION - Type social behaviorism explicitly or tacitly assumed in the - Organization - Frequency post-Darwinian functionalism of James, Freud, and Pia- - Integration - Immediacy get, as well as in contemporary operant, social-cognitive, and psychoanalytic theories. The fact of its perpetual re- emergence in diverse forms over the past century suggests Note. The model incorporates social interdependence (script linkage) into the that this feedback mechanism ranks as one of the more conventional action-outcome feedback model. significant discoveries of modern oxperimental and clin-

September 1991 • American Psychologist 933 the goal are more likely to provoke anger than are inter- promoting action scripts as are health beliefs or attribu- ruptions that occur farther from the goal (Mandler, 1975). tions (Lichtman et al., 1984). Research examining the A partner's negative reactions to interrupted routines can effect of script interdependence on health habit change undermine commitment to new patterns of health be- has the potential to tie self-regulation theory to social havior. contexts and to suggest methods for identifying and un- Note that in this model the degree of disruption, coupling potentially problematic action linkages (Ber- and hence of support from a helper, is predicted by the sheid, Snyder, & Omoto, 1989). degree to which the helper's valued action scripts are in- terdependent with the action scripts of the person needing support (i.e., the degree of action linkage). This explains Processes of Self-Change why measures of relationship satisfaction often fail to Behavioral interventions in populations require an action predict family members' responses to a member's change model that offers explicit procedural guidelines for en- of diet, exercise, or other routines; behavioral support is couraging personal self-regulation (Leventhal, Zimmer- a function of action linkage, whereas relationship satis- man, & Gutman, 1984). The action state model effectively faction reflects the degree to which one's goals for the describes habitual activities in which people react to relationship are being met (Ewart, in press). Families feedback discrepancies occasioned by disrupted routines characterized by high levels of cohesion and satisfaction but does not fully represent processes involved in creating (Olson, Sprenkle, & Russell, 1979) may prove surprisingly new action scripts or modifying ones that prove ineffec- unsupportive when important interlinked routines are tive. The latter processes include "feed-forward" mech- repeatedly disrupted (Coyne, Wortman, & Lehman, anisms by which people create new goals, alter self-stan- 1988); and family environments characterized by lower dards, fashion behavioral strategies, and select new en- levels of cohesion or satisfaction may be conducive to vironments (cf. D. H. Ford, 1987, pp. 67-69). Social- behavior change if action linkage also is low. cognitive research has identified a number of mechanisms Self-regulation theorists have devoted scant attention that enable people to make transitions from old action to the counterintuitive notion that relationship closeness states to new ones, and thus to change. It is useful to view may be a risk factor for nonadherence, and few have con- these transition processes as interacting components sidered that daily routines are as likely to disrupt health- within a general causal model, as in Figure 3. Figure 3

Figure 3 Process (Self-Change) Mode/Representing Self-Regulation as a Coordinated Ensemble of Interacting Cognitive Processes and Capabilities

SOCIAL INTERACTIONPROCESSES - Odentation

- Engagement SOCIAL INTERDEPENDENCE - Control /\

I ...... \/ ",,/., \ / , , \/ MOTIVATION PROBLEM SOLVING I - Outcome - Recognition Expectancies - Definition HEALTH : - Self-Efficacy D PROTECTIVE OUTCOMES - Alternatives = ACTION - Goal Structures - Strategies

ACTION STATES (Habits) GENERATIVE CAPABILmES - Attention Deployment - Information Processing / Retrieval - Action Schemas

SELF-CHANGE PROCESSES

Note. The model incorporates action capabilities of microsocial relationship systems (social interaction processes) into a general causal model of personal change.

934 September 1991 ° American Psychologist introduces a process dimension to indicate that action to identify potential obstacles to self-change and generate states arise from strategies people use when trying to reg- appropriate strategies to overcome them. ulate their behavior, and that the creation of strategies is prompted by motivational appraisal processes. The ability Motivational Processes to make appraisals and translate them into strategies is People are neither impelled by attitudes nor mindlessly a function of health-relevant procedural and factual pulled by reinforcers. Instead, they actively motivate knowledge (generative capabilities), as well as the inter- themselves by envisaging possible outcomes, evaluating personal skills possessed by oneself and by others with their capabilities, and generating goals that guide and en- whom one's action scripts are interlinked (social inter- ergize problem solving. action component). Note that self-change processes (Fig- Outcome expectancies. Decisions to adopt health- ure 3) are connected with action states via the broken protective behaviors are influenced by expectations that line shown in the figure: Disturbance of an action state a recommended action will protect or enhance valued due to internal changes (e.g., fatigue or illness) or external resources or outcomes (Bandura, 1986; Janz & Becker, causes (e.g., disrupted interdependence) may stimulate 1984; Rogers, 1983). Anticipated outcomes include the reappraisal, renewed problem solving, and strategy im- health-promoting activity's intrinsic effects (e.g., the plementation, even as changes in appraisals, by suggesting pleasant physical sensations it produces), as well as its new goals and strategies, may alter existing action states. more extrinsic material and social consequences (e.g., In addition to providing targets for intervention, enhanced personal appearance, social approval, reduced process mechanisms suggest testable pathways through risk). People contemplating a difficult action such as which environments can affect health behavior and pro- quitting smoking carefully weigh the pros and cons of vide new ways for public health epidemiologists and acting; the relative importance they attribute to desired planners to envisage and to investigate person-environ- and undesired consequences of trying to quit predicts the ment interactions. I will return to this important point probability of their acting, as well as the likelihood of later when discussing contextual influences. their maintaining prolonged abstinence (Velicer, Di- Clemente, Prochaska, & Brandenburg, 1985). Leventhal Problem Solving and his associates (Baumann & Leventhal, 1985; Lev- Models of health behavior usually ascribe changes in enthal, Meyer, & Nerenz, 1980) have underscored the role health habits to changes in health knowledge, beliefs, at- of cognitive appraisals by demonstrating that many health titudes, or contingencies of reinforcement (Janz & Becker, choices are shaped by erroneous expectancies derived 1984; Leventhal et al., 1984). It is becoming evident, from idiosyncratic and incorrect "theories of illness." however, that problem-solving activities mediate the im- Public health interventions can alter outcome expectan- pact of these motivators; persuasive inducements affect cies by drawing attention to naturally occurring outcomes behavior only to the degree that they prompt people to (e.g., emphasize immediately experienced benefits of ex- create appropriate self-change strategies. Strategies func- ercise or diet change), as well as by introducing contrived tion as action guides for specific situations and range from incentives (e.g., lottery prizes). In the case of behaviors simple if-then rules used without active awareness (Lin- that are comparatively uncomplicated or easy to perform ville & Clark, 1989) to carefully constructed constellations (e.g., switching to a higher fiber cereal), significant wide- of thoughts, feelings, and actions that help an actor reg- spread change often can be effected by providing infor- ulate arousal, exert control over outcomes, make choices, mation about action-consequence relationships and by and persist in the face of difficult obstacles (Dweck & introducing simple prompts into situations in which the Leggett, 1988; Kihlstrom, 1987; Langer, 1989). self-protective action should be performed (e.g., the gro- Research conducted in the past decade suggests that cery store shelf; Geller, Winett, & Everett, 1982). the ability to generate effective strategies for handling day- Although research in health belief and reasoned ac- to-day problems is related to social and emotional ad- tion frameworks indicates that outcome expectations in- justment, and that adjustment can be enhanced by prob- fluence health behavior, these formulations leave large lem-solving training (D'Zurilla, 1986; Nezu, 1986; Nezu proportions of behavioral variance unexplained (M. H. & Perri, 1989). Moreover, it appears that problem-solving Becker, 1990), thus suggesting the need to identify the activities constitute the fulcrum of the habit-change pro- contributions of other motivational processes. cess. Adherence to dietary regimens is correlated with Self-efficacy. A desire to change does not stimulate problem-solving skill in adults (Fehrenbach & Peterson, problem solving unless one believes oneself to be capable 1989; Glasgow, Toobert, Riddle, Donnelly, & Calder, of performing the recommended action (Bandura, 1977, 1989) and in adolescents (Hanna, Ewart, & Kwiterovich, 1986). Unfortunately, people often are unduly pessimistic 1990). Including problem-solving training in behavioral about their capabilities. Prime examples include the many weight-loss interventions has been shown to effect greater Americans with elevated cardiovascular risk factors who weight loss than has comparable behavioral intervention fail to change their diet and exercise patterns despite a without problem-solving training (Black & Scherba, 1983; desire to do so (Oldridge, 1982). Research in this large Graves, Myers, & Clark, 1988). These findings suggest and important population dramatically illustrates the that, rather than focus only on target behaviors, public power of self-appraisal: In high-risk individuals, increases health interventions should encourage and enable people in self-efficacy following a treadmill exercise test predict

September 1991 • American Psychologist 935 subsequent compliance with prescribed exercise routines patterns by causing people to generate self-directive goals better than do treadmill performance or electrocardio- or behavioral intentions (Fishbein & Ajzen, 1975; M. E. gram data derived from the test (Ewart, Stewart, Gillilan, Ford & Nichols, 1987), together with standards for eval- Keleman, Valenti, et al., 1986; Ewart, Taylor, Reese, & uating one's performance (Bandura, 1988). Directive DeBusk, 1983). Moreover, self-perceived ability to exer- goals embodied in personal projects guide people into cise prior to participating in aerobic exercise training activities and environments that affect their responses to predicts posttraining gains even after controlling for pre- behavior change inducements. Health behavior changes treatment capability (Ewart, Stewart, Gillilan, & Kele- seen to facilitate important projects will be adopted more men, 1986). easily than changes that appear less compatible (Eiser & Research on the origins of self-efficacy suggests ways Gentle, 1988), even when the latter are viewed as desirable to enhance one's personal confidence by means of low (outcome expectancy) and feasible (self-efficacy). For ex- cost, widely applicable interventions involving social ample, after a heart attack, patients are more likely to modeling and graduated performance of feared activities follow a rehabilitative exercise regimen if they strongly (Bandura, in press; Ewart, 1989b, 1990). In people who want to recover energy needed to resume a challenging fear exercise, self-efficacy can be strengthened by per- career than if they are concerned with minimizing dis- forming simple, safe exercise tests. By providing confi- comfort or avoiding work stress (Oldridge, 1982). En- dence-building interpretation of test results as part of couraging weight-loss clients to reflect on their commit- standard medical evaluation, self-efficacy can be enhanced ments and priorities has been shown to help them inte- (Ewart, Taylor, et al., 1983). Principles of self-efficacy en- grate dietary change objectives with valued goals and thus hancement also can be applied to public health com- facilitate clinic-based weight loss (S. H. Schwartz & Inbar- munications to promote participation in preventive Saban, 1988). By surveying people's projects, public screening (Ripplctoe & Rogers, 1987). health planners can gain important insights into higher Goal structures. Although experimental analyses of order goals that motivate a target population, and thus self-regulation usually examine isolated behavioral re- discover ways to make an intervention more attractive to sponses, epidemiologic studies of eating, exercising, or those it is meant to serve. smoking show that these and other health habits belong In addition to developing directive goals, people for- to larger clusters of action scripts directed toward some mulate self-standards by which to judge the adequacy of greater goal, and that such dusters are more prevalent in their efforts. Attaining a goal results in self-approval and some population subgroups than in others (Donovan, thus stimulates further goal-directed effort (Bandura, Jessor, & Costa, 1988). This discovery challenges self- 1989). Public health campaigns can stimulate change by regulation theorists to explain how action clusters are activating self-evaluation, but goal theories differ as to formed and how these structures might affect population whether easy, difficult, or moderately challenging stan- responses to behavior change appeals. Contemporary so- dards inspire the greatest effort (Bandura, 1988; Locke, cial-cognitive approaches to personality provide con- Shaw, Saari, & Latham, 1981). It appears that the optimal structs that may prove useful in addressing these ques- level of challenge depends on the nature of the directive tions. Recent work on personal "strivings" (Emmons, goal (Hyland, 1988). When the directive goal is a physical 1986), "projects" (Little, 1983), "tasks" (Cantor, Norem, state, such as achieving a lower blood cholesterol level or Niedenthal, Langston, & Brower, 1987), and "social lower body weight, comparatively easy goals (e.g., try 2% goals" (M. E. Ford, 1982), for example, suggests that ac- milk before switching to skim milk; lose only one pound tion clusters are constituted by an individual's personal per week) are most effective as they make attaining the projects. These projects respond to basic tasks of living desired end state easier and more certain. On the other such as achieving social influence, being accepted by oth- hand, when the directive goal is to enhance a protective ers, acquiring material resources, establishing intimacy, skill, such as mastering a health-promoting sport or self- or protecting personal safety. Projects change over time control technique, moderately difficult goals should gen- as different age-graded normative tasks become critical erate greater persistence as they ensure a sense of achieve- to negotiating successive developmental phases of the life ment and provide more informative feedback about one's span (Caspi, 1987). For example, eating large quantities capabilities than do very easy or very difficult goals (Ban- of junk foods and experimenting with tobacco, alcohol, dura & Schunk, 1981). or drugs compose a cluster that may serve an adolescent's Judgments concerning personal capabilities and self- goal of being accepted by peers (Jessor, Chase, & Dono- goals are interactive subprocesses; directive goals and self- van, 1980), whereas in an adult, behaviors composing standards affect self-efficacy, and self-efficacy appraisals this cluster often increase in an effort to manage job stress guide the selection of action strategies. This interactive (Johansson, Johnson, & Hall, 1991). Positive affect is as- view raises important questions for social-cognitive the- sociated with the perception that important goals are ory. For example, interventions to enhance self-efficacy being attained and that negative affect is associated with may prove more effective when a person's valued projects low expectations of success or with conflicts among one's aim at achieving mastery goals such as skill or strength various goals (Emmons & King, 1988, 1989; Ruehlman, enhancement than when projects serve end states such 1985). as increasing physical comfort or enjoyment (S. H. Projects affect the creation of self-protective action Schwartz & Inbar-Saban, 1988).

936 September 1991 • American Psychologist Generative Capabilities can impair ability to appraise risk or anticipate possible consequences of health-endangering actions (Weinstein, The acts of solving a problem, formulating a goal, ap- 1988). Public health interventions can enhance action praising one's capabilities, or foreseeing the consequences capabilities by altering inaccurate schemas and providing of behavior draw on various forms of knowledge or sche- useful knowledge and skills. In addition to cognitive con- mas. Cognitive schemas represent organized knowledge trol skills, helpful procedural schemas include skins for sets that direct one's attention to specific aspects of sit- evaluating health-relevant information (e.g., TV com- uations and environments, guide the encoding of expe- mercials, product labels) and reflecting on one's problem- riences in long-term memory, and provide procedural solving efforts. For example, simply teaching people to routines for performing familiar tasks (Winfrey & Gold- monitor and evaluate their problem-solving progress im- fried, 1986). Declarative knowledge schemas represent proves the quality of solutions achieved (Kluwe & Fried- facts and beliefs about oneself, one's body, and the social richsen, 1985), and focusing one's attention on the process and physical world, whereas procedural schemas consist of problem solving is more helpful than focusing on the of skills and rules for applying declarative knowledge final goal (Kuhl, 1985). Mentally envisaging oneself per- (Anderson, 1983). Together, these knowledge forms com- forming a chosen strategy prior to enacting it increases prise generative capabilities that allow one to envisage the probability of success (Nuttin, 1984; Wilensky, 1983). alternative goals and create novel action strategies (Lin- Novel schemas are most easily assimilated when ville & Clark, 1989). As enablers of motivation and prob- presented in the form of a story about an actor (model) lem solving, these generative capabilities constitute im- who successfully confronts a problem scenario in which portant mechanisms by which social and physical envi- the instigating conditions and the actor's goals, behavior ronments affect self-regulatory acts. sequences, and experienced outcomes are clearly specified A class of procedural schemas critical to self-control (Bandura & Jeffery, 1973; Winett, King, & Altman, 1989). was noted a century ago by William James (1890/1950), Retention is enhanced when this material is presented who observed that the essential act of will (self-regulation) following principles known to facilitate cognitive encoding involves "attending to a difficult object" in the form of and retrieval of health-relevant information (Ley, 1977). an imagined possibility that inhibits or energizes action. It appears that schemas involving core assumptions about Contemporary research supports this insight (Kanfer, personal vulnerability may be more difficult to change 1980) and demonstrates that self-control is facilitated by than schemas representing procedural routines or facts skill in cognitively transforming distressing thoughts and about illness (Janoff-Bulman, 1989). People are more aversive stimuli (McCaul & Malott, 1984). Developmental likely to revise vulnerability schemas in response to crises studies of children's ability to delay gratification in the and during transitions into new environments (Cantor, face of temptation reveal that delay is related to the ac- 1990), suggesting that risk education might target those quisition of attention deployment strategies used during undergoing life changes or experiencing an illness or death the waiting interval, knowledge of delay rules, and intel- in their immediate social network (D. Becker & Levine, ligence (e.g., Rodriguez, Mischel, & Shoda, 1989). 1987). Social action theory suggests that cognitive control schemas influence behavioral choices by increasing con- Social Interaction Processes fidence in one's ability to persist in temptation avoidance. Although self-regulation theorists have tended to view ac- This is supported by examination of eating habits in a tion capabilities as properties of the individual, a social- recent epidemiologic study (Slater, 1989). Individuals' contextual view asserts that these abilities are also a func- confidence in their ability to control distressing thoughts tion of an individual's close personal relationships (Ewart, and ruminations (cognitive control) predicted their self- 1990; McFall, 1982). When behavior changes threaten to efficacy for controlling eating behavior, and self-efficacy disrupt a valued relationship, a satisfactory outcome de- (but not cognitive control) predicted their dietary habits. pends on the partners' ability to collaborate effectivelyin Experimental studies provide further evidence that self- problem solving; that is, success depends on partners' efficacy mediates the influences of cognitive schemas; at- conjoint (as opposed to individual) social capabilities. tending to obstacles that might impair one's ability to These capabilities can be enhanced by simple, cost-effec- perform an experimental task lowers self-efficacy, and tive interventions that can be widely implemented in lowered self-efficacy subsequently is associated with im- health care settings. For example, including a cardiac pa- paired performance (Cervone, 1989). Teaching attentional tient's spouse in an exercise stress-test protocol has been control techniques for pain management improves self- shown to increase couple agreement concerning the efficacy for pain control, which in turn is associated with former's physical abilities, thereby removing a significant increased pain tolerance (Bandura, O'Leary, Taylor, interpersonal obstacle to exercise compliance for tertiary Gauthier, & Gossard, 1987). prevention (Taylor, Bandura, Ewart, Miller, & DeBusk, Desire to mobilize control skills is influenced by de- 1985). In a city clinic serving low-income Black outpa- clarative (factual) knowledge. People resort to personal tients, including a family member in brief, behaviorally illness representations (Leventhal, Meyer, & Gutman, specific counseling and regimen planning increased the 1980; Meyer, Leventhal, & Gutman, 1985) to interpret patient's long-term compliance with antihypertensive felt symptoms and diagnostic labels; these representations medications, resulting in improved blood pressure con-

September 1991 • American Psychologist 937 trol, and reduced mortality over a five-year follow-up in- diate milieu. A public health perspective, however, views terval (Levine et al., 1979; Morisky et al., 1983). These individual self-regulation as a subcomponent of larger interventions presumably operate by altering the relevant environmental systems. These systems create contextual knowledge schemas of each of the parties (e.g., demon- influences (the third term in the host-agent-environment strating to a spouse what the patient can do) and pro- paradigm) that constrain or facilitate self-protective acts. moting shared projects, increasing self-efficacy, and A contextual model (Figure 4) thus completes the public building shared commitment to a specific plan of action health paradigm by indicating how environments affect (Black, Gleser, & Kooyers, 1990). self-change processes (Figure 3) to disrupt or maintain a To increase relationship support for self-regulation, given action state (Figure 2). The model guides social and it is necessary to clarify the origins of conjoint (relation- organizational intervention to encourage personal change. ship) competence and to determine how interpersonal This model also challenges the dominant public processes and capabilities influence personal self-control. health view of person-environment interaction, which is Research on marital communication and problem solving a simple mechanistic conception of biological suscepti- suggests that a relationship's competence is a function of bility interacting with an environmental hazard (e.g., lung dyadic orientation processes, defined in terms of the fre- cancer risk increases synergistically in workers whose quency, skill, and persistence with which both partners nicotine-damaged lungs are exposed to airborne asbestos attempt to understand each other's goals, identify shared fibers). Although simple mechanistic models can explain objectives, separate conflict over one goal or project from many public health risks, social action theory introduces other relationship goals and projects, and endorse or val- the possibility of more dynamic, reciprocal relationships idate each other's strivings (Gottman, Notarius, Gonso, between persons and environmental contexts. Personal & Markman, 1976). These activities are facilitated by goals, expectations, skills, and strategies cause individuals engagement processes including reflective listening, efforts to seek or create environments that satisfy their strivings to distinguish a communication's intent from its felt im- and suit their capabilities (Emmons, Diener, & Larsen, pact, and attempts to translate general criticisms into be- 1986); this reciprocal conception helps explain risks that haviorally specific requests (Jacobson & Holtzworth- arise and persist because people actively choose environ- Monroe, 1986). Relationship competence is also increased ments that support health-endangering goals and plans. by control processes, such as specifying clear and attain- For example, longitudinal data from the Framingham able goals, developing action plans, and monitoring their heart disease study suggest that people tend to select implementation (Jacobson & Margolin, 1979). Relation- marriage partners whose degree of obesity, smoking, al- ship deficits in orientation, engagement, and control cohol use, and dietary habits match their own (Sackett, competence are associated with elevated blood pressure Anderson, Milner, Feinleib, & Kannel, 1975). In this view during marital conflict in persons with essential hyper- of interaction, contexts modify personal generative ca- tension (Ewart, Taylor, Kraemer, & Agras, 1991), and pabilities and social relations in ways that affect how peo- conjoint training that targets these skills reduces cardio- ple generate goals, envisage opportunities for action, and vascular reactivity during family arguments (Ewart, Bur- devise and execute health-relevant strategies. nett,& Taylor, 1983; Ewart, Taylor et al., 1984). Contextual determinants of action capabilities. Research on social support indicates that the avail- Public health practitioners need to know how changes in ability of a trusted confidant (typically a spouse) appears work, community, or family environments are likely to to be the critical factor determining whether people feel affect the individual's capacity for self-protective action. they are adequately supported in coping with difficult Among psychologists, interest in this question owes much challenges (HeUer, Swindle, & Dusenbury, 1986). The to the ecological views of James G. Kelly, who has argued analysis of relationship competence identifies interper- that individual behavior responds to normative expec- sonal processes conducive to sustained self-regulatory tations of social settings, that behavioral demands of one support. It suggests that people will anticipate greater setting (e.g., work environment) affect behavior in other support for self-protective activities and feel more con- settings (e.g., family relationships), and that personal fident in their ability to change if they and a trusted other change is constrained by access to important community are able to (a) report multiple mutual goals and projects, resources and by the behavior's compatibility with en- (b) describe their relationship conflicts in terms of specific during communal values or practices (Trickett, 1987). situations and behaviors, and (c) engage in collective goal- Kelly was influenced by Kurt Lewin and his student Roger setting and monitoring (control) activities. Manipulating Barker, who noted that individual differences in behavior these relationship capabilities in studies of behavioral ad- often were more a function of environmental variation herence might disclose more effective ways to increase than of differences in knowledge, attitudes, intelligence, social support for self-protective action. or personality (Wicker, 1979). Others have combined be- havior analysis with Marxist theory (Harris, 1979) to ex- Social Environmental Determinants plain individual behavior in terms of constraints imposed by physical environments, technologies of production, of Self-Regulation and the social roles, organizational structures, and polit- Social-cognitive theories explain self-regulation in terms ical systems to which modes of production and repro- of internal processes and transactions with one's imme- duction give rise (Biglan, Glasgow, & Singer, 1990).

938 September 1991 • American Psychologist Figure 4 Contextual Model Representing Self-Regulation as a Subcomponent of Larger Social and Environmental Systems

ACTION CONTEXTS - Settings SOCIAL INTERACTION Physical PROCESSES Task Social SOCIAL INTERDEPENDENCE - Relationship systems - Organizational systems \1/ V MOTIVATIONAL D[ PROSLE" APPRAISAL SOLVING - Mood / Arousal Energy vs. Fatigue (Positive Affect) Subjective Distress PROTECTIVE OUTCOMES (Negative Affect) -]:IACTION GENERATIVE CAPABILITIES

- Temperament - Biological Conditions ACTION STATES SELF-CHANGE PROCESSES (Habits)

CONTEXTUAL INFLUENCES Note. The model specifies contextual influences that, by altering microsocial relationships and personal generative capabilities (self-change processes), empower or constrain the development of self-protective habits (action states).

Attempts to explain individual behavior in terms of Social relationships affect personal action by shaping social organization or structure have a long history in physical and interpersonal environments. Relationships sociology and cultural anthropology (e.g., Giddens, 1979; entail a range of benefits, expectations, and obligations Parsons, 1949). These literatures suggest that environ- that influence health-relevant goals and strategies. 3 For mental settings and social systems affect personal behavior example, the cooperation of a spouse enhances compli- by channeling a person's interpretations of events, af- ance with diet, smoking, and exercise interventions (Black fecting one's biological condition, influencing the for- et al., 1990; Cohen & Lichtenstein, 1990; SaUis et at., mation of close relationships, and interacting with phys- 1987) and with substance abuse treatments (Wiens & iological processes to generate mood states that bias cog- Menustik, 1983), yet relationship systems also impose nition and constrain social interaction (e.g., Kohn & social obligations that may interfere with self-protective Schooler, 1982). Social action theory (Figure 4) assists in activities (Riley & Eckenrode, 1986). Peer networks pro- analyzing these influences--and person-environment vide contacts with others who can assist with problems, interactions in general--by characterizing settings and enhance self-efficacy by suggesting effective strategies, and systems in terms of the goals they activate and the personal bolster self-esteem by advocating more favorable self- capabilities, social interactions, motivational appraisals, evaluative standards (Thoits, 1986). These relationships and action strategies they support. also provide social models whose behavior facilitates or Settings, defined as the physical features of one's en- inhibits action patterns; consumption of alcohol or to- vironment, the tasks routinely performed there, and the bacco by heavy drinkers or smokers increases in the pres- people composing one's proximal social milieu, influence ence of model who is drinking or smoking (Collins & action goals and strategies by determining access to Marlatt, 1981; Kniskern, Biglan, Lichtenstein, Fry, & needed material resources such as health-enhancing foods or exercise facilities (Kerr, Amante, Decker, & Callen, 1982; Oldridge, 1982), as well as energy resources in the s Socialroles and accompanyingnorms ofconduct oftenare invoked to explain how social systemsinfluence individual behavior. Roletheory form of information, time, and money. Health promoters has been subject to a number of critiques (Lyman & Scott, 1975; J. E have acknowledged the importance of settings by intro- Scott, 1971), including challenges to the simplistic notion that society ducing health behavior change programs into the worksite supplies the roles to which actors adapt as best they might and to the (Cataldo & Coates, 1986); however, a contextual per- questionable assumption of strong normative consensus about the be- spective suggests the importance of restructuring work haviors the individual must execute. To quote Giddens (1979), "Social systems are not constituted of roles, but of (reproduced) practices" (p. settings and tasks so as to alter stressful conditions that 117); depending on one's position in the system, these practices entail contribute to health-damaging habits such as smoking a range of perogativesand obligationsthat an actor may decideto activate and lack of exercise (Johansson et al., 1991). or carry out.

September 1991 • American Psychologist 939 Bavry, 1983). Similar effects have been demonstrated in This concern is evident in the field of community eating behaviors (Rosenthal & McSweeney, 1979). psychology, in which investigators have shown increasing Organizational structures at the level of government, interest in "phenomena of empowerment" (Rappaport, economic, educational, and health care systems channel 1987). Empowerment is at once an individual and a social individuals' goals, expectations, and strategies in diverse construct, referring both to a sense of personal control, ways (Altman, 1990; Winett et al., 1989). Systems of pro- mastery, and power to effect change, and to a group's or duction, distribution, and promotion, together with gov- organization's ability to control community resources, ernment regulatory policies, affect exposure to settings, engage in collective decision making, and achieve shared products, and messages that influence health choices goals (Chavis & Wandersman, 1990). Individual empow- (Gorn & Goldberg, 1982; Wadden & Brownell, 1984; erment is seen to flow from collective empowerment; po- Warner, 1986). litical arrangements that empower groups by giving them Physical settings and social systems both affect and ownership of material resources, information, and deci- interact with biological structures and processes within sion-making authority foster individual empowerment of the person to create intrapersonal contexts that influence group members by providing direct experience in orga- goals and generative capabilities. Physical and social en- nizing people, identifying resources, and developing vironments modify cognitive skills by affecting the growth strategies for achieving goals (Zimmerman & Rappaport, of the nervous system and by providing social experiences 1988). that change the ways children, adolescents, and adults A connection between the two types of empower- perceive contingencies, appraise their abilities, and solve ment is suggested by data showing that people who take problems (Hanna et al., 1990; Nicholls & Miller, 1984). an active role in community organizations score higher Biologically based differences in temperament apparent than do less-involved peers on such empowerment indexes at birth and persisting over the life span influence personal as internal locus of control, belief that people can influ- preferences for social interaction, tolerance for novel ence political decisions, self-esteem, and personal sense stimuli, intensity of activity, and emotional arousability; of mastery (Kieffer, 1984; Zimmerman & Rappaport, these differences contribute to differential socialization 1988). Although the direction of causation remains to be experiences affecting acquisition of health-relevant goals, clarified, the theory is significant in specifying organi- expectations, and skills (Goldsmith et al., 1987; Kagan, zational structures that may affect an individual's ability Reznick, & Snidman, 1988). to take self-protective action and in generating guidelines Social and biological influences combine to generate for organizing groups and effecting political and institu- mood states, which reflect combinations of energy level tional changes to support self-protective behavior (Chris- or positive affect, and subjective distress or negative affect tenson & Robinson, 1989). (Watson & Pennebaker, 1989). Emotional arousal affects Social action theory aids this task by specifying me- attention deployment; under high arousal, people are less diating mechanisms linking organizational structures to able to detect stimuli, attend to their own behavior, or personal health. For example, community empowerment appraise the long-term consequences of personal decisions will affect individual community members differently, (Jarvis, 1982). Mood and arousal also influence the type according to their personal projects, generative capabil- of health information encoded into memory, the degree ities, exposure to social models, and the availability of to which it is actively processed, and ability to retrieve it supportive feedback (Bandura, 1986). Moreover, social later (Bower, 1981; Leventhal, 1970; Petty & Cacioppo, action theory suggests that empowerment is not a unitary 1986). Moreover, emotional expression or inhibition may construct; organizational forms may differ with respect affect behavioral control; for example, anger inhibition to the number and type of personal goals, capabilities, in response to provocation has been shown to increase and action strategies they enhance. Participating in an subsequent alcohol consumption by social drinkers organization with a rigid ideology and hierarchical lead- (Marlatt, Kosturn, & I_ang, 1975). Emotional distress also ership structure may foster one's sense of social empow- can impair interpersonal problem-solving capabilities, erment (e.g., commitment to the organization's goals and thereby affecting relationship support for personal change. confidence in its political influence) yet fail to enhance individual empowerment defined as capacity for self-pro- Social Contexts and Empowerment for Self-Change tective action (Pargament et al., 1987). Other structures Contextual influences determine the success of interven- could increase a sense of self-mastery without building tions to promote self-protective behavior. Social action the conviction that through collective action people can theory provides a useful taxonomy for organizing inter- shape their social destiny or might foster some personal vention strategies, as shown in Table 1. Behavioral re- action components (e.g., commitment to self-change search has focused on techniques that facilitate desired goals) at the expense of others (e.g., self-change skills). action states; far less is known about the ways in which Individual empowerment should be enhanced by contextual factors influence self-change processes to de- organizations that (a) encourage their members to identify cide the fate of nascent self-control. This is unfortunate, and pursue tasks that match their personal goals, (b) per- as interventions to promote habit changes are difficult to mit forms of participation that match members' capa- implement and sustain without broader social, institu- bilities and allow them to become involved in an incre- tional, or political intervention (Winett et al., 1989). mentally demanding manner, and (c) reward members

940 September 1991 • American Psychologist Table 1 Interventions to Facilitate Health Protective Action States, Activate Self-Change Mechanisms, and Create Contexts That Support Sustained Action in Modifying Diet, Obesity, Exercise, Smoking, and Alcohol Use Intervention Referencesa Facilitating desired action states Stimulus control 1. Brownell, Stunkard, & Albaum, 1980 Introduce/remove environmental cues ~,2 2. Kazdin, 1984 Self-monitoring 3. Martin et al., 1984 Compare personal performance against a monitored 4. Scott, Denier, Prue, & King, 1986 behavioral standard TM 5. Elder, 1987 Reinforcement 6. Ewart, Li, & Coates, 1983 Provide desired short-term consequences to support health- 7. Klesges, Vasey, & Glasgow, 1986 enhancing behavior; remove undesired consequences 2,5 8. Brownell, Marlatt, Lichtenstein, & Wilson, Provide feedback, monetary, material, or social rewards 2,3,5,6,7,8 1986 Aversive control 9. Wiens & Menustik, 1983 Aversive counterconditioning of addictive behavior9 10. Bowers, Winett, & Fredriksen, 1987 Response cost (e.g., fines, loss of advance deposit)2,s,1° 11. Ewart, 1990 Behavioral restructuring 12. Ewart, 1989a Interrupt early components of problem scripts; integrate desired scripts with existing routines; coordinate with scripts of intimate others 2,11,12 Activating self-change processes Problem solving 13. Hanna, Ewart, & Kwiterovich, 1990 Identify dysfunctional strategies; adopt action orientation; 14. Kuhl, 1985 generate and evaluate alternative strategies; formulate 15. D'Zurilla, 1986 action plan 13-15 16. Janis & Mann, 1977 Motivational appraisal 17. Velicer, DiClemente, Prochaska, & Outcome expectancies: Decisional balance sheet Brandenburg, 1985 procedures le-~8 18. Marlatt & Gordon, 1985 Self-efficacy expectancies: Graduated performance and 19. Ewart, 1989a persuasionTM 20. Little, 1983 Goal structures: Project analysis; values clarification; goal 21. S. H. Schwartz & Inbar-Saban, 1988 setting 2,20,21 22. Winett, King, & Altman, 1989 Generative capabilities 23. Botvin, Baker, Botvin, Filazzola, & Millman, Teach self~,ontrol techniques TM 1984 Provide declarative and procedural action schemas via direct 24. Taylor, Bandura, Ewart, Miller, & DeBusk, or symbolic (e.g., TV) modelig 22 1985 Social interaction processes 25. Ewart, Taylor, Kraemer, & Agras, 1984 Peer pressure resistance training23 Family self-efficacy training24 Family problem-solving training25 Creating action contexts Settings 26. King, Carl, Birkel, & Haskell, 1988 Provide needed facilities, time, equipment, foods, 27. Levy, Matthews, Stephenson, Tenney, & personnel 2s,~ Schucker, 1985 Relationship systems 28. Janis, 1983 Develop support groups; implement buddy systems2s,29 29. Cohen & Lichtenstein, 1990 Organizational structures 30. DiFranza, Norwood, Garner, & Tye, 1987 Community organization and collective action to change laws 31. Flay, 1987 and policies affecting work environment; promote healthier 32. Warner, 1986 food standards; control availability and advertising of health- 33. Goldstein, Niaura, Follick, & Abrams, 1989 endangering products s°-32 34. Ewart et al., 1987 Biological conditions 35. King, Winett, & Lovett, 1986 Pharmacologic intervention to alleviate withdrawal symptoms (e.g., nicotine gum) s3 Mood/Arousal Relaxation training34 Stress management training 3s Referencesdescribe the techniquesand document theireffectiveness.

September 1991 • American Psychologist 941 for their contributions. These conditions should be facil- (Figure 4) offers an integrative action schema for defining itated by a flexible leadership structure, open sharing of public health goals and identifying modifiable personal information and decision making, moderate group size, and social-contextual influences that can be activated to and collective control of necessary resources (Zimmerman encourage self-protective activities. The framework is de- & Rappaport, 1988). Research comparing effects of dif- signed to facilitate interdisciplinary collaboration in ferent organizational structures on self-regulatory sub- public health research by coordinating the perspectives processes represents a vital yet undeveloped zone of con- of psychology with perspectives of the biological, epide- tact between social-cognitive theory, community psy- miological, and social-organizational sciences. chology, and the field of public health. Social action theory develops new agendas for a public health psychology. Social contextual analysis raises Social Contexts and Stages of Self-Change questions concerning the role of social interdependence Social-contextual analysis also has implications for the and interaction in self-regulation and proposes a number view that habit changes occur in a sequence of qualita- of testable hypotheses about processes that mediate con- tively distinct behavioral stages (Horn & Waingrown, nections between environmental changes and personal 1966; Kristeller & Rodin, 1984; Prochaska & Di- behavior. To address these questions effectively, it will be Clemente, 1983). A stage conception is useful if proposed helpful for psychologists to receive public health training stages reflect different functional mechanisms or processes and to collaborate in research with investigators from of self-change. 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